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When Is Discectomy Indicated for Lumbar Disc Disease?

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When Is Discectomy Indicated for Lumbar Disc Disease? Evidence-based answers from the Family Physicians Inquiries Network Kisha Young, MD; Rhett Brown, MD Carolinas Medical Center When is discectomy indicated Department of Family Medicine, Charlotte, NC for lumbar disc disease? Leonora Kaufmann, MLIS Carolinas Medical Center, Charlotte, NC EvidEncE-basEd answEr ASSISTANT EDITOR emergent discectomy is indicat- caused by lumbar disc disease provides Anne L. Mounsey, MD University of North A ed in the presence of cauda equina faster relief of symptoms than conservative Carolina, Chapel Hill and severe, progressive neuromotor defi- management, but long-term outcomes are cits (strength of recommendation [SOR]: equivalent (SOR: A, a systematic review C, expert opinion). and randomized controlled trial [RCT]). Elective discectomy for sciatica instant Evidence summary viewers concluded that, for patients with sci- Lumbar disc disease is the most common atica caused by lumbar disc prolapse, surgery poll cause of sciatica.1 In the absence of red flags, provides faster relief from the acute attack QUESTION the initial approach to treatment is conserva- than conservative management; long-term tive and includes physical therapy and anal- differences in outcome are unclear.1 Under what gesic medications. In 90% of patients, acute A more recent systematic review of circumstances do attacks of sciatica improve within 4 to 6 weeks 5 studies that compared surgery with conser- you recommend without surgical intervention.1,2 vative management of sciatica concluded that discectomy? Experts agree that cauda equina syn- early surgery provides better short-term relief 4 n For patients drome is an absolute indication for urgent of sciatica but no benefit after 1 or 2 years. with significant surgical intervention.3 Most also would con- neuromotor deficits. sider surgery for patients with progressive Despite faster recovery with surgery, or severe neuromotor deficit, although no questions remain n Only if the pain persists despite controlled studies exist to support this rec- A subsequent study randomized 283 patients conservative ommendation.3 If surgery is necessary, dis- with severe sciatica for 6 to 12 weeks to early treatment. cectomy to relieve nerve compression is the surgery or prolonged conservative treatment current standard of care.3 with surgery if needed.5 Primary outcomes n Only if neither were functional disability, intensity of leg conservative treat- ment nor epidural Surgery provides relief, pain, and the patient’s self-perceived recov- steroid injection at least in the short term ery. Of patients in the early surgery group, relieves the pain. A Cochrane review of 4 RCTs compared open 89% (125/141) underwent microdiscectomy and microdiscectomy with nonoperative after a mean of 2.2 weeks. n I rarely recommend discectomy. management of lumbar disc disease in pa- At 1 year, intention-to-treat analysis tients with sciatica.1 All the studies showed a showed no significant difference in disabil- n Other______________ tendency toward improved early outcomes ity, pain, or perceived recovery between the with surgery. However, the results of the 2 groups. However, patients who underwent studies were limited by lack of adherence to early surgery reported faster relief of leg treatment, with high crossover rates from con- pain and a faster rate of perceived recovery. Go to jfponline.com servative treatment to surgical intervention. The median time to perceived recovery was and take our instant poll Microdiscectomy produced comparable 4 weeks (95% confidence interval [CI], results to standard open discectomy. The re- 3.7-4.4) for early surgery and 12.1 weeks (95% 490 ThE JourNal oF FamIly PracticE | AUGuST 2011 | Vol 60, No 8 CI, 9.5-14.9) for prolonged conservative treat- • progressive or significant neuromotor ment. Both groups had a 95% recovery rate at deficit 52 weeks. • neuromotor deficit that persists after 4 to Thirty-nine percent (55/142) of patients 6 weeks of conservative treatment randomized to conservative management un- • chronic sciatica with positive straight leg derwent surgery after a mean of 18.7 weeks, raise longer than 6 weeks or uncontrolled and this lack of adherence to intention to treat pain. may limit the validity of the results. A follow- up study at 2 years continued to show no dif- The ICSI recommends that patients being ference in outcomes between surgery and considered for nonemergent surgery have an conservative treatment.6 epidural steroid injection, which may allow them to advance in a nonoperative treatment program.2 Recommendations The American College of Physicians The Institute for Clinical Systems Improve- guidelines agree that most patients with lum- ment (ICSI) recommends conservative man- bar disc herniation will improve within the agement initially for acute low back pain with first month with conservative management. sciatica/radiculopathy because the condition They recommend discectomy or epidural ste- usually improves in 4 to 6 weeks. Surgery is roid injections as potential treatment options indicated in the following cases: for patients whose symptoms persist despite Most experts • cauda equina syndrome conservative therapy.7 JFP would also consider surgery for progressive references or severe 1. Gibson JN, Waddell G. Surgical interventions for lumbar disc a systematic review. Eur Spine J. 2011;20:513-522. neuromotor prolapse. Cochrane Database Syst Rev 2007;(2):CD001350. 5. Peul WC, Van Houwelingen HC, Van den Hout WB, et al. Sur- 2. Institute for Clinical Systems. Health Care Guideline: Adult gery versus prolonged conservative treatment for sciatica. deficit despite a Low Back Pain. 14th ed. Bloomington, MN: Institute for Clini- N Engl J Med. 2007;356:2245-2256. lack of controlled cal Systems Improvement; 2010. Available at: www.icsi.org/ 6. Peul WC, Van den Hout WB, Brand R, et al. Prolonged conser- low_back_pain/adult_low_back_pain__8.html. Accessed vative care versus early surgery in patients with sciatica caused studies. March 2, 2011. by lumbar disc herniation: two year results of a randomised 3. Awad JN, Moskovich R. Lumbar disc herniations: surgical controlled trial. BMJ. 2008;336:1355-1358. vs nonsurgical treatment. Clin Orthop Relat Res. 2006;443: 7. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment 183-197. of low back pain: a joint clinical practice guideline from the 4. Jacobs WC, Van Tulder M, Arts M, et al. Surgery versus conser- American College of Physicians and the American Pain Soci- vative management of sciatica due to a lumber herniated disc: ety. Ann Intern Med. 2007;147:478-491. Primary Care Management of Patients With Asthma • The role of small- and large-airwayTHE JOURNAL OF inflammation in Free the pathogenesis of asthmaFAMILY 1.0 CMe credit • Assessing asthma severityP throughRACT validatedICE questionnaires and spirometry • Initiating and adjusting therapy • Long-acting ß-agonists (LABAs) for persistent asthma • The importance of patient self-management in asthma control To read the supplement online and earn a free 1.0 CME credit, visit: www.jfponline.com/Pages.asp?AID=9594 FACULTY To listen to the companion Clinical Conversations Stephen A. Brunton, MD, FAAFP audiocast and earn an additional free Free AudiocAst 0.5 CMe LeRoy M. Graham Jr, MD, FCCCP 0.5 continuing medical education (CME) credit, credit Stuart W. Stoloff, MD, FAAAAI, FAAFP jfpoNline.comvisit www.jfponline.com/Pages.asp?AID=9520.Vol 60, No 8 | AUGuST 2011 | ThE JourNal oF FamIly PracticE 491 Sponsored by the Primary Care Education Consortium and supported by an educational grant from Teva Pharmaceuticals..
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